Medical tourism safety fears

SAFETY fears about the growth of medical tourism have been heightened as an Australian health insurer forges ahead with dental and cosmetic surgery packages in Thailand.

In a Perspectives article published by the MJA, Associate Professor David Greenfield and Dr Marjorie Pawsey, of the Australian Institute of Health Innovation at the University of NSW, decried the lack of regulation of the medical tourism industry, which includes cosmetic, dental, cardiac and orthopaedic procedures, bariatric surgery, organ and tissue transplantation, and in-vitro fertilisation. The industry is valued at more than US$20 billion globally. (1)

They wrote that there were important unanswered questions about the industry, including its impacts on patient safety and national biosecurity: “How many consumers return to Australia with nosocomial infections? What types of infections are being introduced into primary care and hospitals? What are the risks for health professionals?”

The authors warned there were limited and untested regulatory frameworks in countries offering medical tourism, and asked how quality and safety claims of overseas health care organisations were assessed. They said there was no certainty over the legal protections available to medical tourists.

Professor Greenfield told MJA InSight the federal government regulated hospitals and the insurance industry “so it’s their role to set up a framework for medical tourism and monitor the industry”.

Earlier this year health insurer NIB launched a new service providing Australian customers with cosmetic surgery and dental services in Thailand. (2)

NIB would not disclose to MJA InSight how many patients had accessed the overseas service. When asked whether patients with complications would be followed up in Australian hospitals with Medicare footing the bill, a spokeswoman responded: “The location for follow-up would be assessed on an individual basis to ensure it best meets our customer’s needs”.

She said that to date, no patients had required the company’s “after care promise” which covered follow-up treatment for up to 12 months.

NIB said all of its associated international facilities had been approved and reviewed by its own specialist independent accrediting body as well as the US-based Joint Commission International.

“Overseas, nibOptions will only contract with registered, fully certified and experienced surgeons with at least 5 years of postgraduate training and 12 years of medical and surgical education”, the spokeswoman said.

However, Professor Peter Collignon, professor in infectious diseases and microbiology at the Australian National University clinical school, told MJA InSight that even with these safeguards, serious infection risks remained.

“Around the world, including in Australia, 5%‒10% of people will get an infection during a hospital admission”, he said. “However, if you get an infection in a developing country such as China, India or Thailand, where antibiotic-resistant bacteria are present in much higher numbers than in Australia, chances are you will have bacteria that are much harder to treat.”

“What are the plans in place for this predictable number of people?”

Professor Collignon said medical tourists who returned with infections were invariably treated in Australian public hospitals, including with intravenous therapy with expensive and sometimes non-registered drugs, because antibiotics listed on the Schedule of Pharmaceutical Benefits were ineffective against most resistant bacteria acquired in overseas health care settings.

He said he had seen several cases of multiresistant bacterial infection in returned medical tourists, including patients who travelled to India for cosmetic surgery and for a kidney transplant. (3)

However, several Australian hospitals are also exploring opportunities to cash in on medical tourism through inward bound consumers.

Dr Sue Matthews, the chief executive officer of the Royal Women’s Hospital in Melbourne, told MJA InSight the hospital was “looking at what is feasible, and what would sit with our philosophy as a public hospital”.

“It is about us sharing our knowledge and expertise as much as the possibility of caring directly for international inpatients”, she said. “Revenue will be a factor in this decision as well, as it could possibly allow us to fund further expansion of services.”

Federal Health Minister Peter Dutton did not respond to MJA InSight’s request for comment on regulating the medical tourism industry.

A hazard not mentioned to date, are infections by the blood borne viruses, hepatitis B and C and HIV. These are highly prevalent in many developing countries and with the reuse of inadequately sterilised needles, syringes and other instruments, are an ever present risk. And if B or C are acquired and become chronic, who will pick up the tab for prolonged continuing treatment?

I agree with Clem that the risk of acquiring a blood borne virus is significant within some countries in our region offering medical tourism. These safety concerns firstly need to be clearly highlighted to those who are considering cosmetic surgery packages in Thailand and other countries in Asia. Secondly, testing for blood borne viruses would be wise for anyone who has had invasive surgical or dental treatment in a country of high viral hepatitis or HIV prevalence.